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Cystoscopy with photodynamic diagnostics (PDD)


Medical editor Bjørn Brennhovd MD
Urologist
Oslo University Hospital

General

Hexaminolevulinate is a pharmaceutical product developed for diagnosing urothelial cancer in the bladder, and is used in combination with cystoscopy. An instillation of hexaminolevulinate before cystoscopy will identify changes in the urothelium by showing a change in color of the urothelium. This examination is called photodynamic diagnostics (PDD). 

There is very little toxicity associated with this substance.

Indications

  • Examination for superficial urothelial cancer of the bladder, especially for suspected cancer in situ in patients with confirmed or suspected urothelial cancer.
  • Monitoring of high risk patients
  • Support for TUR-B in special cases

Goal 

  • Diagnostics (better sensitivity for detection of cancer in situ)
  • Monitoring (more accurate for detection of recurrence)
  • Support during treatment (TUR-B)

Equipment

  • Catheterization set 
  • Hexaminolevulinate kit containing 85 mg powder and 50 ml fluid for dilution
  • Laparoscopy rack
  • CE brand cystoscopy equipment with necessary filter to allow both standard cystoscopy with white light and cystoscopy with blue light

Preparation

  • Prepare instruments for sterile catheterization. 
  • Prepare the hexaminolevulinate solution. The hexaminolevulinate powder is mixed together with fluid to prepare a solution. Each glass bottle of powder contains 85 mg of hexaminolevulinate in the form of 100 mg hexaminolevulinate hydrochloride.
  • Transfer 50 ml of the solution to a sterile 50 ml syringe. Add about 5 ml of the fluid to the glass bottle containing the powder.
  • Carefully shake the bottle to dissolve the powder.
  • Transfer the solution back to the 50 ml syringe and carefully mix. 
  • Add about 5 ml of the solution from the syringe to the glass bottle again and then aspirate the solution, repeating two more times. Check to make sure all the powder is transferred to the syringe.  
  • The final solution should be clear, colorless, or light yellow.
  • The solution should not be stored for more than two hours after mixing.
  • It is recommended to dispose of any unused solution.

Implementation

  • About one hour before cystoscopy:
    • Insert the disposable catheter by sterile procedure 
    • Empty the bladder
    • 50 ml the hexaminolevulinate solution is instilled in the bladder via the catheter 
    • The patient should keep the fluid in for about 60 minutes before emptying the bladder 
    • After emptying the bladder, cystoscopy with fluorescing light should be initiated within 60 minutes
  • The patient should be brought from the urology department where the solution was instilled to the operating room for cystoscopy. 
  • Cystoscopy with or without general anesthesia:
    • The cystoscopy instrument is inserted into the bladder via the urethra. 
    • Examine the changes in the bladder urothelium by examining the patient with the help of white and blue light. During the examination with blue light, any changes will emerge as a colored area in the bladder. 
    • If needed, biopsies are taken from suspect areas under white light.

Follow-up

Observations

  • The hexaminolevulinate rarely causes side effects.
  • Blood may be present in urine along with dysuria the first days after the procedure. 

Follow-up

  • Scheduled on an individual basis according to the diagnosis and treatment schedule. 

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